Section C - Employment history for the last 5 years

Previous Employer name and address if current employer is less than five years (attach a separate sheet if necessary).

58. From YYYY-MM to YYYY-MM

59. Employer's name

60. Street address

61. Apt.

62. City

63. Province/State

64. Postal/Zip code

65. Country

Section D - Additional Information

66.

Have you ever been convicted of an offence in any country for which you have not received a pardon? (No/Yes)

Have you ever received a waiver of inadmissibility to the U.S. from a U.S. government agency? (No/Yes)

Have you ever applied to the Minister of Citizenship and Immigration Canada (CIC) for rehabilitation? (No/Yes)

Have you ever been found in violation of customs or immigration laws? (No/Yes)

If you have answered YES, please give details;

For U.S. background checks, you may be questioned by a U.S. officer about your full criminal history, including arrests and pardons.

Section E - Certification

U.S. Privacy Act Statement

The authority to collect the information on this application, any supporting documentation, fingerprints, and other requested information is contained in Titles 8 and 19 of the U.S. Code and corresponding regulations. Furnishing the information on this form is voluntary; however, failure to provide all the requested information may result in the delay of a final decision or denial of your request. The information collected will be used to make a determination on your application. It may also be provided to other government agencies (Federal, state, local, and/or foreign) as permitted under the Privacy Act of 1974, 5 U.S.C. § 552a (2002) and other applicable law. All applicants are subject to a check of criminal information databases and other immigration and customs databases in order to determine eligibility for this program.

Canada's Privacy Statement

The information you provide on this form, including supporting documentation and biometric data, is collected under the Customs Act and is protected under the Privacy Act. The information will be used to make a determination of your application and may be shared with other government agencies in Canada and the United States of America. The information will be retained in the Personal Information Bank # CCRA PPU 042. Instructions for obtaining information are provided in Infosource which is available at public libraries, Government public reading rooms and on the Internet at: http://infosource.gc.ca.

Consent Statement

I understand that any information gathered for the purposes of this application, including any supporting documentation, background information, biometric data, and information obtained from the relevant files of law enforcement agencies, including intelligence gathered for law enforcement purposes, will be used for the purpose of the operation of the FAST
program and to conduct applicable checks and verifications to determine eligibility and continued eligibility in the FAST program as described in the Presentation of Persons (2003) Regulations. My contact information may also be used by the CBSA to send me notifications related to changes to the FAST program.

In addition, I understand that my personal information gathered for the purposes of this application, including my supporting documentation, background information, biometric data, and any other information obtained and collected for the purpose of the operation of the FAST program and to conduct applicable checks and verifications to determine my eligibility and continued eligibility in the FAST program, may be accessed and used by the CBSA, as well as by other government departments or agencies in Canada (including the Royal
Canadian Mounted Police and the Canadian Security Intelligence Service), in accordance with the Privacy Act.

In addition to the above-noted use by the CBSA and other Canadian government departments and agencies, I also understand that the CBSA will share its determination of my eligibility to the FAST program, based on Canadian criteria, with the United States Department of Homeland Security (DHS). The DHS will, in turn, disclose to the CBSA its determination of my eligibility based on the American criteria.

If you do not consent to the above-noted collection, use and sharing of your personal information, your application cannot be processed and an authorization cannot be granted.

Do you consent to the above-noted collection, use, and sharing of your personal information AND do you certify that all information given on this application, and in support of this application, is provided voluntarily and is true, accurate, and complete, and that you have read, understood, and agree to abide by all conditions applicable to the program to which
you apply and to the use of the associated authorization, including all instructions and notices accompanying this application?

(Yes/No)

Applicant

Name (print)

Signature

Date

For office use only

68. The applicant has paid the application processing fee.

CPC no.

FAST ID no.

Section F - Fee payment (non-refundable)

69. The combined fee for an applicant to the FAST program is $50 CAN. All credit card fees will be processed as Canadian funds.

I am enclosing a certified cheque or money order payment to the Receiver General For Canada